The Patient's Right to Information: Influence of Socio-Professional Factors in Primary Care
Derecho de información de los pacientes: influencia de las características socioprofesionales en atención primaria
a Área de Medicina Legal, Universidad de Murcia, Murcia, Spain.
b Centro de Salud de Espinardo (Murcia), Área de Medicina Preventiva y Salud Pública, Universidad de Murcia, Murcia, Spain.
c Medicina Legal y Forense, Universidad de Murcia, Murcia, Spain.
d Medicina Legal y Forense, Universidad of Murcia, Murcia, Spain.
Palabras ClaveJob satisfaction. Information. Communication. Primary care.
KeywordsSatisfacción laboral. Información. Comunicación. Atención primaria.
ResumenObjectives. To describe the information provided by primary care doctors to their patients in different phases of the care provision process and to analyse any relationships with socio-professional factors. Design. Descriptive, cross-sectional study based on postal questionnaire. Setting. Primary care centres in Murcia, Spain. Participants. 227 family physicians. Interventions. Distribution of a questionnaire which includes: a) socio-professional variables (age, sex, marital status, years in practice, years in present post, work environment, previous training, number of patients on list, number of patients seen daily); b) an evaluation of job satisfaction (Likert scale) related to salary, career choice, immediate superiors and daily surgery; and c) the frequency with which information is provided to patients concerning diagnosis, prognosis, treatment, complementary examinations and personal, professional and family impact. Main measurements and results. The reply rate was 59%. The percentages of doctors who always provided information concerning diagnosis, prognosis, treatment, complementary examinations and person, professional and family impact was, 23.3%, 7%, 64.3%, 40.5%, and 9.7%, respectively. There was a direct and statistically significant relationship between job satisfaction and the information provided to patients, the doctors feeling most satisfaction providing the most information on the different phases of the care process. On the other hand, there was an inverse and statistically significant relationship between the number of patients on the doctors' lists and the information provided. Conclusions. The degree of fulfilment of the patient's right to information is low. Doctors should realise the practical importance of clinical information in their work. There is a general feeling of discontent amongst family doctors, which has a negative impact on their professional activity. A lighter workload would significantly improve the extent to which doctors provide patients with information and mechanisms should be put in place to improve working conditions to avoid the non-fulfilment of the patient´s right to information.
The right to health information and, more specifically, the right to information on the illness and treatment alternatives is one of the basic pillars of the doctor-patient relationship and an internationally recognised right. Currently, the Law 41/2002 of Patient Autonomy and of the rights and obligations as regards clinical information and documentation recognised in its Article 5 on the rights of the patient to health information, which becomes, therefore, an obligation of the doctor.
Informing the patient is based on the right to health protection and on patient freedom. Its aim is to guarantee the success of treatment by providing the patient with the data which will enable him/her to accept and understand their illness, to organise and adapt their behaviour during treatment and it allows the doctor to give coherent explanations throughout, as well as justifying his advice and decisions during the disease process.
One of the characteristics which defines the specialty of Family Medicine is the development of a continuous relationship between the doctor and the patient.2 Therefore, information in primary care has some peculiarities, since it is a continuous and continued process, made up of the accumulation of small parts of the patients' lives and the sum of a collection of decisions which have to be taken each time, and which makes it different from the information process in the hospital environment. Several studies have been carried out to find out what information is given to the patient by questioning them directly; however, there is not much data obtained directly from the professionals themselves.
Several studies carried out in different countries agree that the motivation and satisfaction of family doctors has decreased significantly over the last few years and that discontent in these professionals is widespread. As a professional group, family doctors are at odds with the current situation in which they carry out their professional work and they present sufficiently unified opinions as regards the need to carry out specific reforms.3
The importance of professional satisfaction lies, among other factors, in that the quality of the services offered in a health system is directly related with the level of satisfaction of the professionals who work in it and its links to motivation. Ignoring the needs for satisfaction and motivation of the professionals can turn into situations characterised by a sense of distancing, depersonalising and professional inadequacy, and the subsequent loss in the quality of the services.
The objective of the study is to describe the information given to patients by primary care doctors during the care process and to analyse whether it is related to the socio-professional factors in which their care work is carried out.
Pacients and methods
Type of Study
Descriptive cross-sectional study.
The sample was obtained from all the family doctors who practiced in the different health centres in the Murcia Region in the year 2002.
The size of the initial sample was 385, calculated with a P=.5, a precision of 5% and a 95% confidence level. The selection of the doctors was carried out by stratified random sampling.
The data was obtained by a validated and self-administered questionnaire. The brainstorming technique was used in the preparation of the questionnaire, in which 7 family doctors and 3 university lecturers took part.
To study the internal consistency in a first phase, the questionnaire was answered by 30 doctors who gave suggestions for improvement and, with the results obtained the Chronbach alpha test ( * =.87) was applied, resulting in 11 items to define the
social/work factors (Table 1), 4 items which established job satisfaction in daily practice (measured using a 1 to 5 Likert scale), the belonging to a professional group, salary and conduct of their immediate superiors, and 5 items to evaluate the frequency in which the professionals informed their patients on the diagnosis, prognosis, treatment, complementary examinations, and the work and the social/family impact of its process.
Data Collection Method
The questionnaires were sent by post and it was requested that the primary care team managers distribute them to the family doctors at the selected centres and that they completed them voluntarily and anonymously. The responses were sent to the researcher in a sealed envelope.
For the statistical analysis of the data the SPSS 11.0 package was used; the programs applied were simple frequency distribution and the association between variables (Pearson * 2).
The final sample was 227 family doctors, which represented a response rate of 59%. Out of a total of 72 primary care teams, 56 replied to the questionnaire (77.7% of primary care teams in the region).
Social-Work Factors of the Professionals
The social-work factors of the sample studied are set out in Table 1. The professionals surveyed were mainly in the 36-55 years age range (84.6%), males were almost double that of females, and the majority were married. The majority of doctors (52.4%) were in the group with 11-20 years of professional practice, followed by the group with 21-30 years experience (26%). As regards length of time in the post at the time of filling in the questionnaire, 30% were less than 3 years, followed by 26% with 3-5 years. These figures decreased progressively until arriving at the group who were more than 15 years (11%). The work environment where the majority of professionals practiced was a semi-urban one.
The previous training of these professionals was mainly through the National Intern/Resident Physician Training Programme (MIR) in Family and Community Medicine, and a small proportion had gained the title of Specialist by different assimilation courses or by other specialties.
They performed their activity mainly and exclusively in the public sector. The number of patients allocated to each doctor is generally between 1901-2100 (32.6%) and only 20.3% have less than 1500 registered patients. The majority of doctors see 41-50 patients per day and practice in a teaching centre.
Job Satisfaction of the Doctors
The mean levels of satisfaction of these doctors (determined using a Likert 1-5 scale, 5 being the highest level of satisfaction) as regards salary, belonging to a professional group, performance of their superiors and daily consultations are as follows, respectively: 2.59 (95% confidence interval [CI], 2.47-2.71); 3.24 (95% CI, 3.11-3.37); 2.33 (95% CI, 2.18-2.48); and 3.01 (95% CI, 2.89-3.13).
Information During the Phases of the Health Care Process
50.7% of the doctors only provided oral information to the patients; the remainder gave combined oral and written information. Only 23.3% of the doctors always informed the patient of the initial diagnosis. Exclusively, 7% of the doctors always informed the patient on the prognosis, a percentage which increased to 64.3% when it was information regarding therapeutic treatment. As regards the reason for complementary examinations, 40.5% always gave information. Finally, only 9.7% always gave information on the social-family and work impact which their illness can make. The questions asked and the percentages obtained are set out in Table 2.
We observed that there is a statistically significant increase in the number of doctors who provide information to patients more frequently in the different phases of the care process when the level of professional satisfaction is higher in the various aspects assessed (Figure 1).
We found a statistically significant relationship between age and the information on the complementary examinations; those who, in the main, always inform their patients are the ones younger than 35 years (65%; P>.001). We also found a significant indirect relationship between the number of registered patients and the information provided to patients on the diagnosis, and the indications for the complementary examinations. The majority of professionals with less than 1500 registered patients always provided information on the diagnosis (45.7%; P<.001), treatment (93.5%; P<.001) and complementary examinations (63%; P=.014) (Figure 2).
Comparison with data from other studies is difficult, since in the majority of studies looked at, they included patients and health users as study subjects to evaluate the amount and quality of health information given, or in some cases, they were centred on direct observations of this situation in the clinic.4 However, our results come from the personal assessment of the doctors, with which we evaluate not specific operations, but the general performance which is normally practised as regards the providing of information to their patients.
It should be underlined that the patient's right to information can be dissociated from any act of will on their part, so the information does not always have to be conceived as a pre-condition of free therapeutic choice by the patient, but it does entail the right to know the state of their health and its process at all times. This right to health information not only applies to the ill patient, but also to the healthy one, to gain access to their right to health protection, which will allow them to adopt preventive measures or life attitudes which could benefit their state of health.5
The results obtained show that, in almost half the cases, the doctors provide information to the patient almost exclusively orally, while the remainder use a combination of oral and written. As regards the initial diagnosis, treatment and complementary examinations, a high percentage of family doctors always or almost always inform (93.3%, 99.6%, and 89.4%, respectively). These percentages decrease on information on the prognosis and the social-family impact of the process (69.7% and 60.7%, respectively), probably due to caution when faced with these 2 phases of the health process in primary care. However, it must be pointed out that the number of doctors who always inform only in the case of information on treatment, is in excess of 50% (64.3%), while information on the diagnosis (23.3%), the prognosis (7%), the complementary examinations (40.5%) and the social-work and family impact of the process (9.7%) is deficient. Therefore, we consider that compliance to the duty of informing does not reach sufficient levels, a fact which is in agreement with other investigations carried out in the primary care4 and hospital environment.8
There is serious concern, from the health sector, on the quality level of the care provided to the community, as well as the level of user satisfaction, but less attention is paid to the work-related health of health professionals themselves.
However, it has been established that professional dissatisfaction entails a serious social and economic cost, due to its effect on the work climate, the salary and the provision of health care.9 The level of quality of services provided in a health system is directly related with the level of satisfaction of the professionals who work in it, it highlights that their demoralisation is the main difficulty which the directors and managers of health centres have to face up to.10,11 Different factors which cause dissatisfaction in doctors have been investigated and in many studies, the perception of loss of autonomy has been identified as one of the most important factors.12-15 Different authors also mention that patient workload, bureaucracy, limited resources, the inadequate communication with medical specialists and the inability to maintain a continuous relationship with patients, particularly factors which limit patient care and decrease the quality of care, increase professional dissatisfaction.16-18 To the list of causes of dissatisfaction, specific problems can also be added, lack of incentives and professional salary.19,20
We have found that family doctors are dissatisfied, particularly as regards economic reward and with the performance of their immediate superiors, and only achieve an intermediate level of satisfaction or indifference as regards their daily practice and the belonging to a professional group. In Spain, other authors have shown this professional demotivation and dissatisfaction.21,22 It also needs to be taken into account that professional satisfaction affects patient satisfaction,23,24 since professional dissatisfaction can negatively influence the behaviour of the patient, as for example, in the compliance of medical treatment, bringing about a decrease in health quality.25
The results we have obtained show that professional satisfaction measured in several ways and health workload measured as the number of registered patients is significantly associated with the information provided to the patients. Generally, we observed that there is a progressive increase in the number of professionals who always inform as professional satisfaction increases, and the professionals with a lower number of registered patients inform their patients more. This enables us to highlight the negative consequences of professional dissatisfaction and the high health workload on the right to patient health information.
We can conclude that compliance with the right to information does not reach satisfactory sufficient levels. There is generalised work dissatisfaction among family doctors which negatively influences the rights of the patient to information. An acceptable workload significantly improves the information provided to patients.
Sufficient interest needs to be generated in the professional so that they accept the practical importance of clinical information in their work activity, not only as a legal requirement, but also as a therapeutic element of confidence and reinforcement in the health process.
Bibliografía1.Ley 41/2002 de 14 de noviembr.e, básica reguladora de la autonomía del paciente y de derechos y obligaciones en materia de información y documentación clínica. BOE n.º 274-2002 de 15 de noviembre de 2002.
2.Stephens GG. The intellectual basis of family practice. Tucson: Winter Publishing Company; 1982.
3.Shearer S, Toedt M. Family physicians´ observations of their practice, well being, and health care in the United States. J Fam Pract. 2001;50:751-6.
4.Barca Fernández I, Parejo Miguez R, Gutierrez Marín P, Fernández Alarcón F, Alejandre Lázaro G, López de Castro F. La información al paciente y su participación en la toma de decisiones clínicas. Aten Primaria. 2004;33:361-7.
5.Galán Cortés JC. El consentimiento informado del usuario de los servicios sanitarios. Madrid: Colex; 1997.
6.Pérez-Moreno JA, Pérez Cárceles MD, Osuna E, Luna A. Información preoperatoria y consentimiento informado en pacientes intervenidos quirúrgicamente. Rev Esp Anestesia Reanim. 1998;45:130-5.
7.Pinto I, Vigil D. Legibilidad de los documentos de consentimiento informado en radiología vascular e intervencionista. Radiología. 1998;40:9-12.
8.Osuna E, Lorenzo MD, Pérez-Cárceles MD, Luna A. Informed consent: evaluation of the information provided to elderly patients. Med Law. 2001;20:379-84.
9.Aranaz JM, Mira JJ, Benavides FJ. Los profesionales y la calidad asistencial hospitalaria. Todo Hospital. 1994;112:35-40.
10.Álvarez Gallego E, Fernández Ríos L. El síndrome del burnout o el desgaste profesional (I): revisión de estudios. Rev Asoc Esp Neuropsiq. 1991;11:257-65.
11.Artacoz L, Cruz I, Cubells JL, Moncada I, Lluis S, Sánchez Miguel A. Estrés y tensión laboral en enfermeras y auxiliares de clínica de hospital. Gac Sanit. 1996;10:282-92.
12.Donelan K, Blendon RJ, Lundberg GD, Calkins DR, Newhouse JP, Leape LL, et al. The new medical marketplace: physicians' views. Health Affairs. 1997;16:139-48.
13.Schulz R, Scheckler WE, Moberg DP, Johnson PR. Changing nature of physician satisfaction with health maintenance organization and fee-for-service practices. J Fam Pract. 1997;45:321-30.
14.Murray A, Montgomery JE, Chang H, Rogers WH, Inui T, Safran DG. Doctor discontent: a comparison of physician satisfaction in different delivery system settings, 1986 and 1997. J Gen Intern Med. 2001;16:451-9.
15.Skolnik NS, Smith DR, Diamond J. Professional satisfaction and dissatisfaction of family physicians. J Fam Pract. 1993;37: 257-63.
16.Kerr EA, Mittman BS, Hays RD, Zemencuk JK, Pitts J, Brook RH. Associations between primary care physician satisfaction and self-reported aspects of utilization management. Health Serv Res. 2000;35:333-49.
17.Kitai E, Kushnir T, Herz M, Melamed S, Vigiser D, Granek M. Correlation of work structure and job satisfaction among Israeli family physicians. Israeli Med J. 1999;1:236-40.
18.deVoe J, Fryer GE, Hargraves L, Phillips RL, Green LA. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care. J Fam Pract. 2002;51:223-8.
19.Hueston WJ. Family physicians´ satisfaction with practice. Arch Fam Med. 1998;7:242-7.
20.Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians' experience of financial incentives in managed-care systems. JAMA. 1999;282:261-6.
21.Sobrequés J, Cebriá J, Segura J, Rodríguez C, García M, Juncosa S. La satisfacción laboral y el desgaste profesional de los médicos de atención primaria. Aten Primaria. 2003;31:277-33.
22.Arce Arnáez MA, Martínez Aguayo C, Sánchez Ludeña ML. El clima laboral en los trabajadores de Atención Primaria. Gac Sanit. 1994;8:79-84.
23.Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122-8.
24.Linn LS, Yager J, Cope D, Leake B. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA. 1985;254:2775-82.